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Table 1 Case report form

From: A multi-centre randomised trial to compare the effectiveness of geriatrician-led admission avoidance hospital at home versus inpatient admission

  Study period
  Baseline Day 3 Day 5 1 month 6 month 12 month
 Eligibility screen X      
Informed consent X      
Screening log X      
 Randomisation X      
 Assessment form X X X X X X
Demographics X      
Presenting problem X      
Place of assessment X X X X X X
Patient status (‘living at home’)   X X X X X
Subsequent admissions     X X  
 Adverse event log   X X X X X
 Barthel Index of Activities of Daily Living X     X  
 Confusion Assessment Method (CAM) X X X X   
 Charlson Co-morbidity Index X     X  
 Health Service Use Questionnaire X     X  
 Short Form of the Informant Questionnaire on Cognitive Decline in the Elderly (Short IQCODE) X      
 Montreal Cognitive Assessment (MoCA) X     X  
 EuroQol five-dimension five-level (EQ-5D-5 L) X     X  
 Patient feedback form     X   
 Difficulties in Questionnaire completion Form X X X X X  
 Death form Completed on patient death
 Discontinuation form Completed when a patient withdraws or is lost to follow-up